To the Editor:
The World Health Organization's goal of providing antiretroviral therapy to 3 million people by 20051 has spurred concerns regarding inadequacies of the health care infrastructure in African countries for administering drugs and monitoring patient progress.2,3 Moreover, the recent report on “brain drain” due to emigration of nurses and doctors from Africa4 has made numerous recommendations for expanding the health care infrastructure while respecting the rights of health professionals to seek jobs abroad. With more than 25 million people stricken by HIV/AIDS in Africa and the low school enrollment rates,5 it is not obvious whether goals of national and international agencies are attainable. In view of the urgency of the situation,6,7 we suggest policies that can increase the supply of health care staff, though with the time lag necessary for training additional staff.
Increasing the Supply of Health Care Staff in African Countries
The procurement of generic antiretroviral drugs by developing countries with support from the Global Fund for AIDS, Malaria and Tuberculosis8 will enable many HIV-positive individuals to live healthy and productive lives. Potential shortages of nurses and doctors, however, can hamper administration of drugs and entail lower-quality care, especially for patients not responding to the cocktail of stavudine, lamivudine, and nevirapine. Moreover, nutrient deficiencies can lower the body's ability to fight disease; HIV progression and anemia are interrelated even in well-nourished populations.9
Further, with a decline in life expectancy in African countries and HIV-positive status of many health care staff, there is clearly a need to train additional nurses and doctors. However, the gross enrollment rates in secondary education were low in 2001, ranging from 6.5% for Niger to 86% for South Africa.10 Moreover, in countries such as Botswana and Zimbabwe where secondary enrollment rates are moderately high, many school teachers are HIV positive; children's education is hampered by teacher absenteeism and premature parental deaths that can force children into remunerative activities.11 Thus, subsidies for primary and secondary education12 are essential for increasing the future supply of health care staff.
Three sets of issues are important for policy formulation. First, compensating developing countries for the loss of nurses and doctors emigrating to developed countries such as United States and United Kingdom should not be based on costs of training in developing countries.4,13 This is because unlike the export of commodities, migrating staff are paid the going salaries in developed countries, reflecting their “market value.” Thus, the principle of “opportunity costs” should be applied to developed countries themselves, ie, reimbursement should be based on funds that would have been spent training in developed countries. Such a strategy would also avoid misallocation of resources in developed countries where shortages of nurses, for example, may be due to low wages.
The estimation of costs for training nurses and doctors in developed countries is complicated by subsidies received by medical institutions for degrees and residency. Based on postcollege education for 2 years for nurses and 4 years for doctors, costs of education in the United States in 1990 were $133,312 and $191,884, respectively.14 The corresponding figures in 2003 prices would be approximately $200,000 and $300,000. These are conservative estimates, because subsidies for certain specializations can be 3 times the direct costs.15 Thus, apart from voluntary restraints, developed countries recruiting staff from African countries should be required to deposit the funds with an agency such as the Global Fund that can compensate developing countries for emigrating staff and subsidize salary increases. Part of these payments, however, can be recovered by employers from the newly recruited African staff by setting up repayment schemes that are analogous to repayment of education loans in the United States. Because medical staff can be replaced slowly in Africa, it would be helpful to delay the starting dates of appointments for recruited staff.
Second, there are likely to be shortages of medical teaching staff in countries such as Burundi, Eritrea, Lesotho, Mali, and Niger where enrollment rates in tertiary education were <3%10; the figures for Botswana and South Africa were 4.7% and 14.6%, respectively. It is therefore essential for other countries to facilitate medical training for African students. However, it would not be a good use of resources for Africans to receive training in medical schools in developed countries in part because incentives to return to their native countries would be small. Instead, it would be advantageous to send additional African students to developing countries such as India and the Philippines for training.
The costs of training nurses and doctors in developing countries are low and funds from the Global Fund can be used to expand medical facilities. For example, the cost of 4-year medical training including tuition and housing in government-supported medical colleges in India is approximately $6000. Allowing for a 200% subsidy from the government and assuming a 6-year training period for doctors, India can train an African nurse and a doctor for $18,000 and $27,000, respectively. These figures are comparable to the fees charged by private medical colleges in India that have greater capacity to absorb students. Moreover, training awards should include travel costs and stipulate that students return to their native countries for a certain period. This approach is in the spirit of “globalization” in the production of services but is motivated by the need to care for millions of sick Africans.
Third, training additional nurses and doctors in African countries, when feasible, entails a diversion of resources from skilled occupations such as engineering and businesses that are “productive” sectors of the economy. This reallocation will in part be compensated by increases in productivity of HIV-positive individuals. Economic consequences of the ongoing antiretroviral “roll-out” plans in countries such as Botswana and South Africa would provide insights into sustainability of such programs. However, without an HIV prevention drive, roll-out programs are unlikely to achieve the desired objectives. This is because high HIV prevalence rates increase the demand for health care services and also the incentives for emigration; safety concerns in the workplace and for children of the staff as they enter adolescence compound the problems.
Alok Bhargava, PhD
Department of Economics University of Houston Houston, TX
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